Percutaneous transluminal renal angioplasty with stenting for stenotic venous bypass grafts: report of two cases
© Kusakabe et al.; licensee Springer. 2013
Received: 24 July 2013
Accepted: 10 September 2013
Published: 12 September 2013
Cases of percutaneous transluminal renal angioplasty for renal artery stenosis are increasing. However, percutaneous transluminal renal angioplasty with stenting for stenotic venous bypass grafts has never been reported. Herein, the authors describe two cases of percutaneous transluminal renal angioplasty with stenting for a stenotic venous bypass graft. The patients in both cases had undergone bypass grafting using autologous saphenous veins, which were anastomosed directly to their abdominal aortas. We successfully conducted percutaneous transluminal renal angioplasty with stenting. One of the keys for technical success is an appropriate selection of guiding catheter compatible with postoperative nonanatomical vasculature, and the other is relatively high pressure dilation for venous stenosis.
KeywordsAngioplasty Renal artery Stents Venous grafts
Percutaneous transluminal renal angioplasty (PTRA) was first described in 1978 (Gruntzig et al. 1978), and has been conducted for the treatment of renal artery stenosis for more than thirty years. Cases of PTRA for renal artery stenosis are increasing with the increase of atherosclerotic diseases and recognition of renovascular hypertension.
Other than PTRA, surgical procedures are also performed for renal vascular diseases and have the same problem, restenosis of treated vessels, as PTRA. In the field of coronary artery, percutaneous coronary intervention (PCI) for stenotic venous bypass grafts is generally conducted as one of the way of salvage (Hernandez-Antolin et al. 2009; Hong et al. 2001; De Feyter et al. 1993). There is a report about PTRA for stenotic venous bypass grafts (Garfinkel et al. 1984). However, the detailed procedure was not mentioned in the literature and PTRA with stenting for stenotic venous bypass grafts has never been reported.
We successfully conducted PTRA with stenting for stenotic venous bypass grafts in two cases. Herein, we describe those two cases and review the keys for technical success.
Although there are many reports about PCI for stenotic venous bypass grafts (Hernandez-Antolin et al. 2009; Hong et al. 2001; De Feyter et al. 1993), there is only one report about PTRA for stenotic venous bypass grafts (Garfinkel et al. 1984). However, the detailed procedure was not mentioned in the literature and PTRA with stenting for stenotic venous bypass grafts has never been reported. Considering that cases of atherosclerotic disease are increasing, cases of venous bypass grafting for atherosclerotic renal artery aneurysm and PTRA for stenotic venous bypass grafts will increase in the future.
In each of our two cases, PTRA was performed for the stenotic venous bypass graft, which had been grafted for the treatment of renal artery aneurysm and was anastomosed directly to the abdominal aorta distal to the renal artery branches nonanatomically (Figures 1 and 3). Although we generally use a guiding catheter which shape of the tip is curved such as renal double curve or hocky stick type in PTRA (Zeller and Schwarzwalder 2009), we selected a guiding catheter which shape of the tip is relatively straight compatible with nonanatomical vasculature and could keep the root of the reconstructed venous graft successfully (Figures 2a and 4a). We used the different type of guiding catheter in two cases. It is because the shape of the proximal side of anastomosed venous bypass graft was different in two cases and we selected the appropriate guiding catheter compatible with postoperative nonanatomical vasculature.
Compared with atherosclerotic arterial stenosis, venous stenosis requires high pressure dilation (Trerotola et al. 2005). In each of our two cases, relatively high pressure dilation (14 atm) was additionally required for adequate dilation (Figures 2c and 4c). However, excessive high pressure dilation may lead to the rupture of the vessel. Unlike superficial veins, venous bypass grafts for renal arteries are located deeply in bodies and the rupture of the vessel will need an emergent operation. We think that it is important to select the appropriate size of the balloon for the targeted vessel and to limit the pressure slightly higher than the rated burst pressure of the mounted balloon of the stent product for safe procedures.
Our report of PTRA for stenotic venous bypass grafts represents just two cases and follow-up period after PTRA is short. Therefore, long-term prognosis such as risk of restenosis or course of renal function is not clear. Protection from distal embolism is discussed in the field of PCI for stenotic venous bypass grafts, but was not preformed in our procedures. We should consider long-term follow-up and protection from distal embolism in the future.
Our findings indicate that an appropriate selection of guiding catheter compatible with postoperative nonanatomical vasculature and relatively high pressure dilation for venous stenosis are the keys for technical success in PTRA with stenting for stenotic venous bypass grafts.
Written informed consent was obtained from the patient for the publication of this report and any accompanying images.
Percutaneous transluminal renal angioplasty
Percutaneous coronary intervention.
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